Pre-Employment Health Form For Employees/providers/volunteers In Child Care Centers
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3PRE-EMPLOYMENT HEALTH FORM FOR
EMPLOYEES / PROVIDERS / VOLUNTEERS
in Child Care Centers
This information will be kept on file at the child care setting or designated location. It will be used to maintain a cumulative record of
immunization status and to identify persons with health problems. This information may also be shared with Region of Waterloo Public
Health if an outbreak occurs.
Last Name:
First Name:
Home Address:
City:
Postal Code:
Home Phone (
) __ __ __ - __ __ __ __
Work Phone (
) __ __ __ - __ __ __ __ ext. _______
Child Care Centre:
Home Child Care
General Instructions:
a) Employees/providers are required to have up-to-date immunization, tuberculosis screening history and to
complete this form with information on infectious diseases and general health history as indicated.
b) Volunteers are required to complete this form to provide information regarding immunization, tuberculosis
screening history, infectious disease history and general health information. There is no requirement that
these be up-to-date, although it is highly recommended. Parent co-op volunteers are included in this
category. TB skin testing is not recommended for volunteers who expect to work less than 150 hours/year
(approximately one half day per week).
Please read and complete the following sections:
IMMUNIZATION HISTORY
DATE
It is very important that any persons working with children have up-to-date immunization.
(Year/Month/Day)
Tetanus Diphtheria Pertussis
(i.e., Adacel™) - funded for adults as a one time adult dose, safe
_____/_____/_____
any time after a tetanus vaccine; no need to wait 10 years
If Tetanus, Diphtheria, Pertussis was completed more then 10 year ago:
Tetanus Diphtheria –
_____/_____/_____
should receive a booster every ten year (after receiving tetanus, diphtheria,
pertussis.
st
Measles, Mumps, Rubella
(One dose after 1
birthday. Not required if born prior to 1970 or if
has lab-documented immunity to all three infections. Note: since Aug/11 a second dose of MMR is
_____/_____/_____
recommended for young adults (18-25 years) and persons who received the killed measles vaccine in
1967-1970.)
□
□
Polio
Yes
No
(Initial series given in childhood only - adult boosters are not required except in certain situations.)
Routine adult immunization is available free of charge from your physician if you require a booster.
□
Yes (series completed)
Hepatitis B
(Immunization against Hep B may be beneficial but is not a requirement. Vaccine may be purchased
□
through your family physician.)
No
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